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Background: Minimally invasive adrenalectomy for pheochromocytoma (PCC) is a complex surgical procedure especially because of the haemodynamic instability due to the excessive secretion of cathecolamines, which may result in a considerable risk of conversion and complications., Aim: By a multicentric retrospective study, the authors reported the results of laparoscopic adrenalectomies in patients operated for adrenal pheochromocytomas with the aim of investigating the role of the laparoscopic approach in managing adrenal disease., Methods: Sixty patients, preoperatively treated with a selective alpha1-blocker, underwent 61 laparoscopic adrenalectomies for PCC smaller or larger than 6 cm - group A (≤6 cm), group B (>6 cm). We compared the two groups of patients analyzing haemodynamic instability, operative time, conversion rate, incidence of complications, length of hospital stay and medium and long-term outcomes., Results: In 23 cases tumor was >6 cm in diameter. Average operative time was 165 min, with a 5% conversion rate. There was no mortality and morbidity rate was 8.3%. Intraoperative hypertensive crises were registered in 15% of patients, whereas 5/60 patients had hypotensive crises. After comparing the two groups of patients, no statistically significant differences in terms of haemodynamic instability, operative time, conversion rate, morbidity and length of hospital stay were observed., Conclusions: As a surgical treatment of pheochromocytomas, laparoscopic adrenalectomy is an effective and safe approach, in selected cases even for PCCs >6 cm in diameter, although patients with such large tumors may have a higher conversion rate and more intraoperative hypertensive crises. Preoperative selective adrenergic blockade does not prevent intraoperative hypertensive crises, but by facilitating the pharmacological management of the perioperative haemodynamic instability, may avoid the onset of major adverse cardiovascular complications., (Copyright © 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.)

Hemorrhoidectomy remains the most definitive procedure to treat symptomatic grades III and IV hemorrhoids. However, over the years, several modifications have been made to the original operation to improve the outcomes. A total of 693 consecutive patients with grade III and IV hemorrhoids underwent Ferguson hemorrhoidectomy. Our results serve as a standard for comparison conventional hemorrhoidectomy (Ferguson's technique) with recent methods such as stapled hemorrhoidopexy and LigaSure hemorrhoidectomy. We have obtained a very low rate of post-operative pain after Ferguson hemorrhoidectomy (VAS pain score was 2.47 ± 1.1 after a day, 1.34 ± 0.7 after 7 days and 0.51 ± 0.1 after 2 weeks) as to for stapler and LigaSure procedure in the literature. Moreover, long-term results demonstrate high levels of patient satisfaction (the satisfaction was good in 624 patients after 2 weeks and in 658 patients after 1 year) with a low recurrence rates (7 patients had recurrence after 1 year and 21 patients after 2 years). We believe that Ferguson-closed hemorrhoidectomy could still be, at the moment, the gold standard to which other techniques are compared.

Background: There is a strong association between obesity and infertility, and weight loss can increase fecundity in obese women. In an attempt to determine the effect of bariatric surgery on obesity-related infertility, we reviewed the fertility outcomes after intragastric balloon placement, adjustable gastric banding, sleeve gastrectomy, and gastric bypass in childbearing women with a diagnosis of infertility at a university hospital in Italy., Methods: This was a retrospective study of 110 obese infertile women. We evaluated the effectiveness of bariatric surgery in improving fertility, assessing the influence of age, surgical technique, co-morbidities (hypertension and diabetes), weight loss, and body mass index before and after surgery., Results: Of these 110 women who had tried unsuccessfully to become pregnant before weight loss, 69 became pregnant afterward. The pregnancies proceeded without complications and ended with a live birth. Only the weight loss (odds ratio 20.2, P = .001) and the achieved body mass index (P = .001) after surgery were the predictors of pregnancy., Conclusion: Bariatric surgery might be effective in young infertile obese women who wish to become pregnant. Weight loss appears to be independent from the surgical technique in determining the increase in the pregnancy rate as well as the body mass index achieved at pregnancy., (Copyright © 2012 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: The aim of this study was to evaluate the influence of cavity drainage in the surgical treatment of sacrococcygeal pilonidal sinuses., Methods: The study was prospectively carried out in 803 patients randomized into two groups of respectively 401 and 402 patients. In the first group, primary excision and closure were associated with drainage of the wound; in the second group, the wound was not drained. We have analyzed time off work, time to walk without pain, time to sitting on the toilet without pain, recurrences, and wound infections. We have also evaluated the satisfaction rate and esthetic results., Results: On comparing time off work, time to walk without pain, and time to sitting on toilet without pain postoperatively, there were no significant differences between the two groups. A significant difference between the two groups with regard to wound infection rates (p = 0.5) and recurrence rates (p = 0.6) was not observed. In order to prevent prolonged inpatient stay and social intolerance, this study suggests that the post-operative period is tolerated by a few when a drain was used. The visual analog scale (VAS) in the drained group was 3.2 ± 0.9, and VAS in the non-drained group was 3.5 ± 0.9 with a significant statistical difference (p = 0.0001). As regards the cosmetic appearance of the scar after surgery, we achieved a high satisfaction rate among patients in either group with 82.9% good cosmetic results., Conclusions: The use of a drain, in our experience, appears to be useless in achieving a quick healing of the sacral wound; in addition, it has a low satisfaction rate.

Sarcomas are uncommon malignant tumors arising from mesenchymal tissue, accounting for approximately 10% of soft-tissue sarcomas and less than 1% of all malignant neoplasms. The most frequent subtypes of retroperitoneal sarcomas are liposarcoma. Total surgical extirpation appears the only chance for patient cure since medical therapies have shown little efficacy. We have analyzed our series of 32 retroperitoneal liposarcoma that undergone surgical resection and with at least 5 years of follow-up. We have included 21 patients who underwent a complete resection (R0) and 6 patients who underwent an incomplete resection (R1). However, the operation's goal was a complete tumor resection with tumor-free resection margins. The 5-year survival was 85.7% when we performed a R0 resection, while it was 33.3% when we performed a R1 resection with a significant statistical difference (p = 0.02). Surgery is the gold standard for treatment of liposarcoma. Despite advances in diagnostic modalities, surgical techniques and the adoption of more aggressive procedure, such disease still has a propensity for local recurrence, even after an apparent complete resection. Therefore, locoregional recurrence remains the main cause of death in patients with a retroperitoneal liposarcoma. Moreover when the tumor recurs locally, the treatment of choice is to remove the recurrence. Our experience shows that a complete resection of primary lesions and further resection of recurrences early detected with CT examination could improve the overall survival of patients with retroperitoneal liposarcoma. Moreover in our series, the patients who undergo R1 resection had a worse prognosis.

The prevalence of people who are overweight or obese has increased dramatically in high-income countries over the past 20 years. There is a strong association between obesity and infertility, and weight loss can result in increased fecundity in obese women. The aim of this study is to demonstrate the potential role of intragastric balloon in the treatment of obese-related infertility. This is a retrospective study. A chart review of 27 obese women seen between September 2003 and July 2008 was performed. They all presented with the diagnosis of infertility and had undergone endoscopic intragastric balloon positioning. Among these women who tried unsuccessfully to become pregnant before weight loss, 15 became pregnant afterward. The pregnancies proceeded without complications and ended with live births. An improvement in the fertility status after weight loss has been described, although data on fertility after weight loss following bariatric surgery are still limited. The results obtained in our experience are not different from data reported in literature for bariatric surgery. Therefore, balloon treatment might be effective in young infertile obese women who wish to become pregnant.

Aim: The technique of ultrasound-guided subclavian cannulation was evaluated in our experience assessing the real effectiveness of such procedure., Methods: We have evaluated 297 subclavian cannulation, performed for the placement of central venous catheter both with landmark method (176 patients) and ultrasound guided technique (121 patients) to assess the real effectiveness of the ultrasound-guided technique to reduce the mechanical complication of the subclavian vein puncture., Results: A total of 23 mechanical complications were identified. Of these, 8 were pneumothorax and 15 arterial puncture. Such cases were identified from the pool of patients who had undergone subclavian venous cannulation with landmark method. However these complications occurred only in difficult venous access and teaching procedure performed with landmark method., Discussion: An ultrasound-guided recent technique for the placement of central venous access should be adopted since such technique seems to reduce the incidence of failure and mechanical complications. However it is worth notice that the clinical effect of using ultrasound guidance technique seems to be more significant when the internal jugular vein rather than the subclavian vein is cannulated., Conclusion: Our experience demonstrate that, both in no difficult cases and in no teaching procedures, central venous catheterization using landmark technique seems to be acceptable on both clinical and medico-legal grounds. However the ultrasound guided technique is necessarily required to achieve the reduction of complications in difficult venous access.

When acute cholecystitis is suspected in a very high-risk patient, percutaneous cholecystostomy should be considered as a safe and effective temporary management of patients with gallstones. Whenever possible, percutaneous cholecystostomy should be followed by laparoscopic cholecystectomy. In elderly patients who are inappropriate surgical candidates because of severe concomitant systemic diseases, less invasive treatments may prevent recurrence. Our experience shows the feasibility of percutaneous cholecystostomy to achieve an effective treatment of acute cholecystitis in surgical high-risk patients with a physiologic biliary drainage of gallstones in duodenum to prevent recurrence. Moreover we demonstrated the feasibility of a concomitant percutaneous treatment of biliary disease.

The aim of surgical treatment of fistula-in-ano is to eradicate the suppurative process permanently without compromising faecal continence. The appearance of a recurrence of fistula-in-ano is often due to non-identification of the internal opening by the surgeon, and to the presence of complex fistulae. We evaluated the clinical course of 214 patients in a randomised. controlled trial with respect to the recurrence rate of anal fistula with or without preoperative endoanal ultrasonography. In this study we demonstrate that endoanal ultrasonography was the most accurate diagnostic modality for detecting internal opening and complex fistulae. Therefore, endoanal ultrasonography is reliable and useful in the preoperative assessment of anal fistula, and particularly for decreasing the recurrence rate of this disease.

Taking herbal-extracts to lose weight is an underestimated health hazard. Often, these products contain active agents that can cause acute liver damage. In this case report, a 22-year-old female patient, who presented with a feature of cholestatic syndrome, was so sure that the "natural products" were not dangerous that she did not inform her physicians that she had taken them, making their task that much more challenging. Clinical presentation mimicked acute cholecystitis and the patient underwent a cholecystectomy. Surgery was without any consequences and complications, although it did not completely cure the illness. She later admitted to having taken herbal remedies and this led to the correct diagnosis of phytotherapy-related hepatotoxicity and a successful therapeutic approach. The true incidence of phytotherapy-related hepatotoxicity and its pathogenic mechanisms are largely unknown. It is important to increase the awareness of both clinicians and patients about the potential dangers of herbal remedies.

Surgical resection is the main and most effective treatment for gastrointestinal stromal tumours (GISTs) and for all benign gastric tumours. All such tumours should be approached with the intention of performing complete en bloc removal of the tumour, achieving microscopically tumour-free pathological resection margins. More extensive surgery fails to guarantee better results over time. Consequently, wedge resection of the stomach ensures adequate therapy. Our personal experience with laparoscopic wedge resection for a gastrointestinal stromal tumour is described, demonstrating equivalent efficacy, greater safety, and applicability, and better postoperative results with this surgical approach.

Pulmonary thromboembolism constitutes the third cause of death after cardiovascular accidents and malignant tumours. Prevention is regarded as the most appropriate and effective therapeutic option. Medical antithrombotic therapy is the most common approach, but when antithrombotic therapy with heparin cannot be performed, vena cava filters are necessary devices in many patients and situations. Over the period from 1995 to 2003, 72 patients were admitted to the Surgical Sciences, Orthopaedics, Trauma and Emergency and Biomorphological and Functional Sciences Departments of the Federico II University of Naples. On the basis of their clinical condition and thrombus characteristics, different filters were applied (definitive, temporary, tempofilter). Thorough clinical and imaging follow-up examinations showed the efficacy of vena cava interruption in the prevention of pulmonary embolism, as well as a low complication rate and convenient risk-benefit ratio. Tempofilter, which allows partial interruption of the vena cava for more than 6 weeks, would appear to be the best filtration device. It is effective in the prevention of pulmonary thromboembolism, is durable and does not entail any significant increase in recurrent venous thrombosis, as is the case with definitive vena cava filters.

Carotid endarterectomy and percutaneous transluminal angioplasty are known to prevent cerebrovascular accidents. From January 1997 to December 2002, 47 patients (35 male, 12 female; median age: 65 years) with carotid stenosis were observed. Neurological accidents were reported in 89.4%, while the other 10.6% were asymptomatic. The operative indications for the asymptomatic patients were high-degree stenosis (> 70%) of the internal carotid artery and ulcerated plaques with a moderate degree of stenosis (50%). Preoperative investigations consisted in colour Doppler ultrasonography, arteriography and cerebral CT scans or NMR. Endarterectomy was performed in 35 patients, while the other 12 underwent percutaneous transluminal angioplasty. The operative mortality in the 35 patients undergoing surgery was 5.7% (2 cases) and perioperative strokes occurred in 3 cases (8.6%). After 36 months, 32/35 patients (91.4%) were stroke-free, and one patient died as a result of a stroke. In the group of patients undergoing angioplasty, re-stenosis occurred in 2 cases (16.7%). Our results suggest that colour Doppler ultrasonography is a reliable examination for investigating the carotid axis and that both carotid endarterectomy and percutaneous transluminal angioplasty are safe procedures capable of preventing future cerebrovascular accidents.